A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

Decrease maintenance IV solution infusion rate.

Place the client in a lateral position.

Administer oxygen via face mask at 2 L/min.

Administer misoprostol 25 mcg vaginally.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.

Choice B rationale:

Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.

Choice C rationale:

Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.

Choice D rationale:

Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.

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Correct Answer is D

Explanation

Choice A rationale:

Allowing parents to enter the nursery while wearing masks may be a preventive measure for some situations, but it is not a standard infection control procedure in a newborn nursery.

Choice B rationale:

Airborne precautions are not required for routine infection control in a newborn nursery. They are typically reserved for specific airborne-transmitted infections.

Choice C rationale:

Placing the newborn's foot on a sterile field during a heel stick is a procedure to maintain sterile technique but is not a general infection control instruction for the nursery.

Choice D rationale:

Placing newborn bassinets at least 3 feet apart is a crucial infection control measure in a newborn nursery. It helps prevent cross-contamination and the spread of infections among newborns. Proper spacing allows for better airflow and reduces the risk of contact transmission between infants.

A. The newborn's respiratory rate is irregular. B. The newborn's respiratory rate is 32/min. C. The newborn's pulse oximetry is 91%. D. The newborn is beginning to cough.

Correct Answer is D

Explanation

The correct answer is **d. The newborn is beginning to cough**.

Choice A rationale:

An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.

Choice B rationale:

A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.

Choice C rationale:

A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.

Choice D rationale:

The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.

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A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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